If your anesthesiologist is having trouble getting Medicare reimbursement for monitored anesthesia care (MAC) for endoscopy procedures, it might be time to clarify exactly what is meant by “medical necessity.”

Medicare defines “medical necessity” as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Under the Social Security Act, CMS determines on a case-by-case basis if the method of treating a patient is reasonable and necessary. Even if a service is reasonable and necessary, coverage may be limited or denied if it is provided more frequently than allowed under a coverage policy, or as accepted standard of practice.